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� � City of Orono <br /> � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> 'Qv 0,� PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: <br /> � � <br /> ,� �sv�"� O 1,I <br /> '✓`���;�`� �, ; StreetAddress: Received by: <br /> �' 1� "�" � ' 2750 Kelle Parkwa <br /> � �, Y Y Plan review fee: <br /> L�kESH�4� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ( <br /> Job Site Address: ;�(c�5� L L� P\������ ��=C�(?� �C��'Z �,'j� � � ��� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ No <br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicanf demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: -� <br /> Name: L`� �-t�l.� � ��,���Iv��`t-�-I�1S L, Ce�- -�ttC <br /> State License# �3 �y Expiration Date: 3 . �; � <br /> Phone: - - _3-- � office -7 j, �-�� ��-� , cell <br /> Mailing Address: � S , - � Cit : ' `-�-�,��� � ZIP: �� �— <br /> Contact Person: Applicant is: ntracto�� / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: _ _���-1-j°C� (� ��C����-� <br /> Phone (day): �' '-�- _ �/ ' <br /> Address: �, " '��1_ , f'� <br /> , �� L��� Cit : �-lJQ_'� Z ZIP: �5.�� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review &permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> R roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: � �V - ��''-�,�; � `) <br /> Estimated Construction Valuation of Project(excluding land) $ �C� L�(} -� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually u date ur records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information, the lic ' n n t be issued. <br /> � � <br /> Applicant's Signature: �� Date: ��� ����-� � <br /> Las'Update� 05-04-2009 <br />